Below is a listing of the Social Medicine Projects (with their abstracts) for the 2009 graduating class of the Residency Program in Social Medicine at Montefiore Medical Center:Eleanor Bathory, MD and Sharyn Miskovitz, MD: Perceptions about Exercise among Inner-City Adolescent Girls
Funded by a Community Access to Child Health (CATCH) grant, we conducted three focus groups at the South Bronx High School to determine the perceptions about exercise among inner-city adolescent girls. We recruited female high school students to participate in one of three 60-minute focus groups of 10-11 students each. Our objectives were to understand the perceptions of adolescent girls regarding their involvement in exercise, benefits of exercise, barriers to exercise, and factors that would motivate them to participate in an exercise program. The adolescent girls who participated in the focus groups recognized important psychological benefits of exercise and offered critical information on barriers and motivating factors. Based on these results we held three sample exercise classes (step aerobics, kickboxing, and double-dutch jump rope) and asked the participants to complete a survey after each class. The participants enjoyed all of the exercise classes and were enthusiastic to participate in an after-school exercise program.R. Max Dyksterhouse, MS, MD: Routine opt-out HIV testing in an urban community center
Undiagnosed HIV infection remains a significant public health problem. To address this, the Centers for Disease Control and Prevention revised testing recommendations, calling for routine opt-out HIV screening among adults in health care settings. We examined acceptability of opt-out HIV testing in an urban community health center and factors associated with accepting testing.Sadiqa Edmonds-Myles, MD: The Impact of Mass Incarceration on Children
The term “Mass Incarceration” has been used to describe extraordinarily high incarceration rates seen in working class communities of color. Despite an estimate of 1.5 to 2 million children affected by parental incarceration, little is known about how mass incarceration affects the health of children or the practice of primary care pediatrics. Previous studies have shown various psychosocial effects of parental incarceration, including PTSD, ADHD, depression, and attachment disorders; however very few have evaluated the breadth of patients in low income urban areas affected by this issue, or the effect of mass incarceration on the health care of children. I participated in two related studies to further evaluate these issues.
The first study was completed during Social Medicine Orientation, and involved a joint effort by Department of Family & Social Medicine residents and faculty to assess the prevalence of arrest and incarceration in patients attending primary care clinics in the Bronx. A card study was completed during a 2.5 week period. 118 cards were completed; one third of which were with parents of pediatric patients. 18% of patients (or parents) currently had a family member in jail. 25% reported having been arrested, and 51% reported they or a family member had spent time in jail. On nearly all variables rates were higher for pediatric visits than for adult visits. Clinicians participating in the study reported positive responses to discussing incarceration.
In order to further evaluate the impact of parental incarceration on the health and health care of children, I am currently working on a qualitative study to evaluate access to a medical home among children of previously incarcerated parents. We have conducted a focus group with the staff of Hour Children, a non-profit organization which assists incarcerated mothers with transition and reunification with their children once released from jail or prison. We are also in the process of conducting in-depth interviews with previously incarcerated mothers to learn more about the effect of incarceration on the health and health care of their children.James A. Fausto, Jr., MD: Home- and Office-based Buprenorphine Inductions: a qualitative study exploring patients’ experiences with initiation of opioid addiction therapy
Context: Buprenorphine, a partial opioid agonist, is effective in treating opioid dependence in primary care settings. Initiation of buprenorphine treatment (i.e., induction) is challenging because patients typically must be in opioid withdrawal. Although inductions have traditionally occurred in medical settings, home-based inductions have recently emerged as a new treatment strategy. No studies have examined patientsâ experiences with buprenorphine inductions.
Objective: To explore patientsâ experiences with buprenorphine induction.
Design: This qualitative study used semistructured interviews of patients who underwent buprenorphine induction. Interviews were digitally recorded and professionally transcribed. A coding scheme was developed to capture key themes. Each encounter was coded independently by two of three investigators; coded data were entered into NVivo 8Â® to retrieve thematically-related text.
Setting: A community health center in the Bronx, NY.
Participants: Twenty patients who underwent buprenorphine inductions (10 office-based and 10 home-based inductions).
Results: Narrative themes included: reasons for starting treatment, social supports, health care system engagement, addiction history, and induction experience. Many patients appreciated the anonymity provided by primary care physicians treating their opioid addiction. All patients would recommend buprenorphine treatment to others seeking opioid addiction treatment. Despite a lack of consensus on preferred induction site, all patients valued the potential to customize the induction process to their needs and preferences.
Conclusions: Patients identified that customizing buprenorphine inductions to their needs was important. Incorporating patient-centered strategies with buprenorphine induction appears to be an important for buprenorphine therapy in the primary care settings. These results can help guide buprenorphine treatment in primary care settings.Uriel Felsen, MD, MPH: High rates of clinical factors associated with advanced liver disease in patients with chronic hepatitis C at an urban methadone maintenance program
Background: Chronic hepatitis C (CHC) is a significant cause of morbidity and mortality among injection drug users. While prior studies have demonstrated a high prevalence of CHC among participants of methadone maintenance programs (MMPs), little data exist regarding the clinical factors that impact CHC morbidity and mortality in this population. Mount Sinai Medical Center’s Narcotics Rehabilitation Center (NRC) served approximately 650 patients before closing in 2007. The center offered methadone maintenance, on-site primary care and psychiatric services, and institutional linkages to CHC specialty care. The goals of this study were to elucidate: 1) the CHC-specific healthcare practices at the NRC; 2) the presence of clinical factors associated with advanced liver disease in those with CHC; 3) the presence of co-morbidities complicating or precluding CHC treatment; and 4) the number of patients who accessed CHC specialty services and were treated.
Methods: A chart review of a random sample of active patients was conducted between December 2005 and January 2006. Laboratory data collected included hepatitis C virus (HCV) antibody, HCV viral load, hepatitis A virus (HAV) and hepatitis B virus (HBV) serologies, and HIV status. The CHC-specific healthcare practices reviewed included screening for CHC and vaccinating for HAV and HBV. Clinical factors associated with advanced liver disease included co-infection with HIV or chronic HBV (defined by a positive HBV surface antigen), alcohol abuse/dependence, and duration of infection >/= 20 years. Psychiatric co-morbidity was defined by presence of an axis I diagnosis or a psychiatric medication. Medical co-morbidities complicating or precluding CHC treatment included: malignancy, autoimmune disease, advanced liver disease, renal disease, active alcohol abuse, and other uncontrolled medical conditions. Access of CHC services included being seen by a specialist, undergoing liver biopsy, or having a history of CHC treatment.
Results: 207 charts were reviewed. 98.1% had an HCV antibody test and 99.3% of those that were positive had a confirmatory viral load. Overall, 54.6% (n=113) of participants had CHC. Of those with CHC who were non-immune to HAV, 56.6% were vaccinated for HAV; and 3.1% of those non-immune to HBV were vaccinated for HBV. Of the patients with CHC: 15.0% had HIV, 1.8% had HBV, 41.6% had a history of alcohol abuse, and 70.8% were infected for >/= 20 years. 7.1% of those with CHC actively abused or were dependent on alcohol, 54.9% had a psychiatric co-morbidity, and 22.1% had a medical co-morbidity that impacts CHC treatment. 25.7% of those with CHC accessed specialty services and 12.4% received CHC treatment.
Conclusion: While screening for CHC was successfully integrated into routine care, patients at this MMT would have benefited from a comprehensive vaccination program. Over half of the patients at this MMP were infected with CHC and many of them had clinical factors associated with the development of advanced liver disease, making timely evaluation and treatment even more urgent in this population. Few patients were evaluated for CHC and even fewer received treatment. Targeting on-site psychiatric treatment for those with CHC and strengthening the institutional affiliations with CHC specialty services may have increased the number of patients being treated. As an urban, academically-affiliated MMP, the NRC may be representative of similar MMPs which are well situated to address the current CHC epidemic within their patient population.Thinh Xuan Ho, MD: Conceptual Models Of Hypertension Among Vietnamese Patients In The Bronx
It is well known that better treatment of hypertension is associated with significant improvement in morbidity and mortality. Lack of adherence to treatment has been postulated as an important reason for poor control of hypertension. Among many underlying causes of low adherence to treatment for hypertension, studies identified misunderstanding about hypertension, perceived efficacy of anti-hypertensive regimen, beliefs concerning the necessity of regular medication and the experience of side-effects, as all serving to discriminate between compliers and non-compliers (13, 14). All of these factors are highly culturally shaped (15).
Although there is no available data about control of hypertension among Vietnamese-Americans, few small studies revealed that the level of awareness of hypertension among this population was even lower than that of the general US population. In order to enhance the level of control of hypertension among Vietnamese-Americans, we conducted a qualitative interview study which investigated personal perspectives of hypertension among Vietnamese-American patients with and without the disease. The ultimate goal of this study was to elicit their understanding about hypertension including prevalence, etiology, symptomatology, possible complications, necessary treatment, as well as its impacts on life.Sybil Hodgson, MD & Betsy Mathew, MD: Using PhotoVoice to build Self Identity among Preteens
Photovoice is a medium that traditionally uses photography to stimulate grassroots social action by having traditionally underrepresented members of a community take photographs of the environment from their point of view. Internationally, this has been applied to bring forth the voices of refugees, women, or other marginalized populations. There have been attempts to use photovoice with adolescents to help them become active in their communities and learn from their peers.
This program utilized photovoice to develop self identity among preteens through a five session photography-based curriculum emphasizing integrity, communication, self perception and relationships. Each participant created individual portfolios of all of their photographs and narratives. The curriculum will conclude with a gallery session inviting community members and family to view the photographs and narratives compiled by the participants.Anne Hyson, MD: Evaluation of a directly administered antiretroviral therapy program for HIV-infected people within a community-based harm reduction program
Background and Significance: Ensuring adherence to highly active antiretroviral therapy (HAART) for the treatment of HIV infection is especially challenging among patients who are facing other medical and social challenges, such as active or prior addiction. Studies have demonstrated that adherence is strengthened and outcomes are improved when directly-observed therapy (DOT) is provided for complicated medical regimens through social networks and community-based organizations. Despite this evidence, DOT is not currently a standard of practice to improve adherence and outcomes for HIV therapy. We set out to examine the effectiveness and feasibility of DOT amongst clients who are most at risk of failing HAART because of mental illness or an unstable social situation. Within the drop-in center of a community-based harm reduction organization, we provided specialized DOT called DAART (directly administered antiretroviral therapy) to clients who had been unsuccessful at adhering to antiretroviral therapy on their own. We hypothesized that compared to baseline, six months after enrollment into the DAART program, clients would have a decrease in HIV viral loads and an increase in CD4 counts.
Methods: The study population included HIV-infected individuals who enrolled in the Montefiore/CitiWide Health Services DAART Program from April 1, 2006 to December 31, 2008. The DAART Program was housed in the larger Montefiore/CitiWide Health Services Program, a collaborative program between an academic medical center and a community-based harm reduction organization that provides comprehensive services to HIV-infected individuals in New York City. The following data were extracted from program logs and medical records: date of enrollment into the DAART Program, socio-demographic information, dates and values of CD4 counts and HIV viral loads, and co-morbid illnesses. We used simple frequencies to describe the clients and program outcomes, defined as change in CD4 count of at least 50 cells/mL, and one log change in viral load (copies/mL).
Results: Thirty-four clients enrolled in the DAART Program. The median age was 48 (range 28-60), and 26 (77%) were men. Fourteen clients (41%) were hispanic, 13 (38%) were black, two (6%) were white, and five (15%) declined to answer. The median CD4 count at baseline was 189 cells/mL (range 4-528), and the median viral load was 8866 copies/mL (range <75 to >500000). Twenty-four clients (71%) were exposed to Hepatitis B, 20 (59%) were exposed to Hepatitis C, and of these, 16 (47%) had been exposed to both Hepatitis B and Hepatitis C. Twelve clients were noted in the chart to be actively using drugs, and 12 were prescribed a psychiatric medicine other than a sleep aid. Seventeen clients (50%) had more than one viral load within six months of beginning the study period. Thirteen clients (76%) had a log decrease in their viral load, three clients (18%) had no change, and one client (6%) had a log increase in their viral load. Nine (53%) achieved an undetectable viral load within the six month period after enrollment in the DAART Program. Ten clients (59%) had a significant increase in their CD4 count, of at least 50 cells/mL. One client (6%) had no change, and six (35%) had decreases in their CD4 counts after starting the program.
Conclusion: Despite a high drop-out rate, our data support the hypothesis that directly administered antiretroviral therapy can be an effective intervention to improve adherence and treatment outcomes among some clients with previous nonadherence to HIV therapy. This evidence could be used to obtain funding for a larger intervention that is designed prospectively, which would enhance data collection and follow-up.Christine A Lee, MD:Transgender Adolescents: Understanding Their Psychosocial Challenges and Barriers to Healthcare
Transgender (TG) individuals are those who identify with the gender opposite from their genetic and anatomical sex on psychological, sexual, and social levels. Little data exists regarding the health and psychosocial risks and needs of TG individuals, particularly adolescents. My objective was to determine the health and psychosocial challenges and barriers to healthcare access faced by TG adolescents living in New York City. I obtained an Community Access to Child Health (CATCH) grant from The American Academy of Pediatrics to develop a medical home for TG adolescents in NYC. Then I conducted a qualitative study, utilizing structured in-depth interviews. Adolescents were recruited from two community-based organizations providing services to the TG community. First, participants completed an anonymous self-administered survey to collect general information, and those interested consented to a 30-minute structured in-depth interview. TG adolescents in this study cited multiple psychosocial challenges and systemic barriers to obtaining healthcare. This data provides new insight and builds upon the emerging body of research on TG adolescents. The findings were presented at two national conferences to inform and further educate health care providers.Irina Linetskaya, MD: Montefiore Goes Green: Resident-Led Advocacy for Organizational Change: My recycling project
In January of 2007, Montefiore made an institutional commitment to adopt an environmentally sound waste management strategy aimed to reduce waste and institute recycling. A medical resident attained institutional buy-in from the hospital’s new CEO who committed financial support toward a recycling initiative. The “Montefiore Green Team,â comprising leaders from departments such as engineering, facilities, and public relations, first piloted and evaluated a recycling initiative at CHCC, a satellite clinic in the South Bronx. Lessons learned there shaped the large-scale, Montefiore Medical Center based recycling program. Given the large projected volume of recycling, Montefiore secured lucrative contracts with local recycling contractors to install a free compactor (a savings of $300,000) and haul recycled paper, metal, glass, and oil free of charge, saving rather than costing Montefiore money to divert trash away from landfills.
One year after inception of an institution-wide program, Montefiore has recycled 36 tons of glass, metal, and plastics and 100,000 pounds of white paper. Montefiore’s cafeteria has eliminated the use of 5,000 Styrofoam trays per week, replacing them with recyclable products. Unexpectedly, rather costing money, recycling saves Montefiore over $1000 per week.
Grass-roots activism can catalyze institutional change, dramatically affecting institutional recycling practices. Although medical residents often feel powerless in a hierarchical medical system, they can represent a strong voice for innovation and change.Sharissa Parker, MD: Perspectives on Culture, Food, Diet and Diabetes Among Jamaican Patients in the Bronx
Diabetes Mellitus is a common, costly condition associated with significant morbidity and mortality. One of the main goals of treating patients with diabetes is to produce near-normal glucose levels to prevent the development of diabetic complications. While pharmacological therapies are clearly effective, diabetes trials have repeatedly shown that adding nutrition and lifestyle approaches can be more effective in delaying the progression of the disease than drugs alone. Diet is an important component of diabetes care, yet full cooperation of patients with dietary regimens can often prove difficult to achieve. In minority ethnic groups, distinct cultural beliefs relating to diet, food and eating need to be understood and appreciated by the health professionals that provide care to these individuals. Our goal was to explore significant questions about health behaviors in general and dietary management, as well as the unique beliefs of food and diet among Jamaicans with diabetes in the Bronx.
Using qualitative interview techniques, we investigated the cultural beliefs of food and eating among Jamaicans aged 18-75 with diabetes and their reactions to dietary advice given by their health care professional. In recorded interviews of 10 participants, we found that all participants continued to eat at least one traditional food item after migrating to the United States. All participants were told by their physician to change their diet, but only 20% of physicians were familiar with Jamaican cuisine. Dietary advice was not specifically targeted to the foods participants consume. In conclusion, this study is an important reminder to those providing care to Jamaicans, and all ethnic minorities, of the need to make dietary advice culturally sensitive. Patients recognize the importance of healthy eating; they just need the principles of the advice translated into their own cultural food language.Sharon Phillips Benattabou, MD and Arati Karnik, MD: Perceived Barriers to Contraception in an Underserved Population
More than half of the approximately 6 million yearly pregnancies in the US are unintended. Lack of contraception use and unintended pregnancy are closely related, especially among young, poor women. Homeless women are both an at-risk population for unintended pregnancy and have a greater association of adverse outcomes in pregnancy, such as preterm labor and low birthweight infants. Few studies have been done regarding contraceptive views among homeless women and ways in which to improve access. Contraception is key in this marginalized population which is at high risk both for unintended pregnancy and poor pregnancy outcomes.
Focus groups were conducted with women over the age of 18 at two family shelters located in the South Bronx in hopes of better understanding perceived barriers to contraception for homeless women in New York. Data analysis used narrative theory to extrapolate common themes from transcribed group discussions. Preliminary findings suggest that even sheltered populations with access to on-site clinics and health insurance find lack of patient education, expense, poor clinical rapport with doctors and side effects as some of the limiting factors to using contraception. Continued efforts need to be made to reach this vulnerable population and improved access to reproductive healthcare.Max E. Quintana, MD: Ay doctor me duele! A typical Presentation of Depression in Latino Men.
It is a clinical chart review determining back pain as an initial complaint of depression in latino men between the ages of 20 and 60yo.Michael Reid, MD: Approaches to TB screening and diagnosis in people with HIV in resource limited settings
TB is the main cause of morbidity and mortality in people living with HIV/AIDS worldwide. Early diagnosis and treatment is essential to addressing the dual epidemic of TB and HIV. This study involved reviewing the diagnostic tools currently available to diagnose TB among people with HIV/AIDSLeigh A. Rieper, DO: Implementing a Sustainable Program: Reach Out and Read at Williamsbridge Family Practice
Reach Out and Read trains doctors and nurses to advise parents about the importance of reading aloud and to give books to children at pediatric check-ups from six months to five years of age. Reach Out and Read initiated in September 2007 at Williamsbridge Family Practice. In the first year, over 500 books were distributed during 85.7% of well visits. In order to maintain a sustainable program participation of all providers is needed. Some of the barriers to having 100% participation of providers include time allowance, lack of interest and small pediatric panels.Amit J Shah, MD: Investigation of Interest Towards Yoga and Meditation in an Inner City Population
Meditation and Yoga are two techniques for wellness that have shown efficacy in multiple medical and psychiatric conditions, such as depression, anxiety, hypertension, fibromyalgia, and lower back pain. The degree of interest towards this complementary modalities in an inner city setting is in question. In this survey study, patients from a general medicine clinic in the South Bronx are interviewed and asked multiple choice and open ended response questions for the purposes of assessing who would be interested in yoga and meditation, as well as factors that may influence this interest. If people show interest, then it may be justifiable to allocate resources towards offering and studying their benefits in this populationLauren Shapiro, MD: Transition Clinic
The transition clinic is an open-access clinic that will provide health care to previously incarcerated persons upon their release from prison. Recent studies have shown that the adjusted risk of death upon the initial two week period following release was 12.7 times that of other state residents, and 3.5 times greater over a two year period. The leading causes of death were drug overdose, cardiovascular, homicide, and suicide. The challenges of release involve substantial health risks, in addition to the difficulty of finding a doctor to continue their 30 day supply of medicine they leave prison with. The proposed clinic seeks to mitigate the role that absent or unstable medical care may play.
Our transition clinic is modeled after the only other transition program at the University of California, San Francisco and seeks to address the health and social needs of recently released prisoners. We aim to provide four primary functions; acute stabilization and medication renewal, ongoing primary care to those with chronic medical conditions, training for residents, and research opportunities. Through partnership with the Osborne Society, Department of Corrections, parole officers, and a community health worker we plan to open our doors July 11th 2009.Michele Trela Bowdy, MD: The TRRIP Program: Teens Reducing the Risk of Infections & Pregnancy
The nature of the project was to create & implement a teen peer education program covering the topics of STDs, HIV/AIDS, & pregnancy prevention. Research shows that these programs have great effect on teens’ HIV/AIDS-related knowledge, attitudes/beliefs about risky behaviors, ability to fight negative peer pressure, and time spent helping other youth avoid unprotected sex. The idea stemmed from a similar project that I did as an AmeriCorps*VISTA, while working at a Migrant Health Clinic. I enjoyed the experience I had with the teens then & wanted to do more work in the area of adolescent health. Being that we practice in the Bronx, where we see many teen pregnancies & STDs, I thought it was a much needed program.
The curriculum is meant to promote healthy, responsible choices for teens by giving them information about health topics that will affect them. Through increased knowledge and skill-building sessions, teens will be better prepared to protect themselves against infections and pregnancy. The Program encourages teens to discuss their health concerns with their parents and doctors. We encourage parents to use every chance to discuss health issues with their children. We also encourage parents to help their child learn to access health services provided by physicians and clinics in our community.
posted by Matt Anderson, MD